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<p class="p_Heading1"><span class="f_Heading1">HIV Care Static Form: Family Information</span></p>
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<td valign="top" width="159" bgcolor="#c0c0c0" style="width:159px; height:31px; background-color:#c0c0c0; border: solid 1px #000000;"><p><span style="font-weight: bold;">Form Label</span></p>
</td>
<td valign="top" width="114" bgcolor="#c0c0c0" style="width:114px; height:31px; background-color:#c0c0c0; border: solid 1px #000000;"><p><span style="font-weight: bold;">Database Table</span></p>
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<td valign="top" width="113" bgcolor="#c0c0c0" style="width:113px; height:31px; background-color:#c0c0c0; border: solid 1px #000000;"><p><span style="font-weight: bold;">Field Name</span></p>
</td>
<td valign="top" width="274" bgcolor="#c0c0c0" style="width:274px; height:31px; background-color:#c0c0c0; border: solid 1px #000000;"><p><span style="font-weight: bold;">Business Rule</span></p>
</td>
<td valign="top" width="106" bgcolor="#c0c0c0" style="width:106px; height:31px; background-color:#c0c0c0; border: solid 1px #000000;"><p><span style="font-weight: bold;">De-identified Field</span></p>
</td>
<td valign="top" width="78" bgcolor="#c0c0c0" style="width:78px; height:31px; background-color:#c0c0c0; border: solid 1px #000000;"><p><span style="font-weight: bold;">Required Field</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:15px; border: solid 1px #000000;"><p>First Name</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:15px; border: solid 1px #000000;"><p>mst_Patient </p>
</td>
<td valign="bottom" width="113" style="width:113px; height:15px; border: solid 1px #000000;"><p>FirstName</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:15px; border: solid 1px #000000;"><p>Auto filled</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:15px; border: solid 1px #000000;"><p>Last Name</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:15px; border: solid 1px #000000;"><p>mst_Patient </p>
</td>
<td valign="bottom" width="113" style="width:113px; height:15px; border: solid 1px #000000;"><p>LastName</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:15px; border: solid 1px #000000;"><p>Auto filled</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:15px; border: solid 1px #000000;"><p>ID - Patient Enrollment Number</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:15px; border: solid 1px #000000;"><p>mst_Patient </p>
</td>
<td valign="bottom" width="113" style="width:113px; height:15px; border: solid 1px #000000;"><p>PatientEnrollmentID</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:15px; border: solid 1px #000000;"><p>Auto filled</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:15px; border: solid 1px #000000;"><p>Existing Hosp/Clinic #</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:15px; border: solid 1px #000000;"><p>mst_Patient </p>
</td>
<td valign="bottom" width="113" style="width:113px; height:15px; border: solid 1px #000000;"><p>PatientClinicID</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:15px; border: solid 1px #000000;"><p>Auto filled</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:15px; border: solid 1px #000000;"><p> </p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:60px; border: solid 1px #000000;"><p>Registered at this clinic</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:60px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:60px; border: solid 1px #000000;"><p>RegistrationNo</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:60px; border: solid 1px #000000;"><p>Yes/No; If Yes, then Find Patient button displays and fields are populated with data from the database.<br>
If No, then manually fill in the fields</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:60px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:60px; border: solid 1px #000000;"><p> </p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:30px; border: solid 1px #000000;"><p>Relative First Name</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:30px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:30px; border: solid 1px #000000;"><p>RFirstName</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:30px; border: solid 1px #000000;"><p>This field is auto filled if patient is existing in db; otherwise manually entered</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:30px; border: solid 1px #000000;"><p>Yes</p>
</td>
<td valign="bottom" width="78" style="width:78px; height:30px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:45px; border: solid 1px #000000;"><p>Relative Last Name</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:45px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:45px; border: solid 1px #000000;"><p>RLastName</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:45px; border: solid 1px #000000;"><p>This field is auto filled if patient is existing in db; otherwise manually entered<br>
Can not have duplicate relative name</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:45px; border: solid 1px #000000;"><p>Yes</p>
</td>
<td valign="bottom" width="78" style="width:78px; height:45px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:30px; border: solid 1px #000000;"><p>Sex</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:30px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:30px; border: solid 1px #000000;"><p>Sex</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:30px; border: solid 1px #000000;"><p>This field is auto filled if patient is existing in db; otherwise manually entered</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:30px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:30px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:30px; border: solid 1px #000000;"><p>Age - years, months</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:30px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:30px; border: solid 1px #000000;"><p>AgeMonth<br>
AgeYear</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:30px; border: solid 1px #000000;"><p>These fields are auto filled if patient is existing in db; otherwise manually entered</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:30px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:30px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:30px; border: solid 1px #000000;"><p>Relationship Type</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:30px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:30px; border: solid 1px #000000;"><p>RelationshipType</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:30px; border: solid 1px #000000;"><p>Select list; This select list is a customized, restricted list</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:30px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:30px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:30px; border: solid 1px #000000;"><p>Birth/Marriage Date</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:30px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:30px; border: solid 1px #000000;"><p>RelationshipDate</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:30px; border: solid 1px #000000;"><p>If Child or Spouse/Partner is selected in the Relationship field, then display this date field</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:30px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:30px; border: solid 1px #000000;"><br>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:30px; border: solid 1px #000000;"><p>HIV Status</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:30px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:30px; border: solid 1px #000000;"><p>HivStatus</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:30px; border: solid 1px #000000;"><p>Only display this field if Existing Patient = No<br>
Select List options: Positive, Negative, Unknown</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:30px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:30px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="bottom" width="159" style="width:159px; height:45px; border: solid 1px #000000;"><p>HIV Care Status</p>
</td>
<td valign="bottom" width="114" style="width:114px; height:45px; border: solid 1px #000000;"><p>dtl_FamilyInfo</p>
</td>
<td valign="bottom" width="113" style="width:113px; height:45px; border: solid 1px #000000;"><p>HivCareStatus</p>
</td>
<td valign="bottom" width="274" style="width:274px; height:45px; border: solid 1px #000000;"><p>Only display this field if Existing Patient = No<br>
Select List options: In HIV Care, On ART, Not in HIV Care, Died, Unknown</p>
</td>
<td valign="bottom" width="106" style="width:106px; height:45px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="bottom" width="78" style="width:78px; height:45px; border: solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td valign="top" width="159" style="width:159px; height:45px; border: solid 1px #000000;"><p>Print</p>
</td>
<td valign="top" width="114" style="width:114px; height:45px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="top" width="113" style="width:113px; height:45px; border: solid 1px #000000;"><p>Print</p>
</td>
<td valign="top" width="274" style="width:274px; height:45px; border: solid 1px #000000;"><p>This button is used to take hard copy of the form. This is basically feature of paperless, but is implemented for non paperless too</p>
</td>
<td valign="top" width="106" style="width:106px; height:45px; border: solid 1px #000000;"><p> </p>
</td>
<td valign="top" width="78" style="width:78px; height:45px; border: solid 1px #000000;"><p> </p>
</td>
</tr>
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